Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up.

OBJECTIVE: The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. METHODS: The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. RESULTS: The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. CONCLUSION: Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Access to chiropractic care and the cost of spine conditions among older adults.

OBJECTIVES: Chiropractic care is a service that operates outside of the conventional medical system and is reimbursed by Medicare. Our objective was to examine the extent to which accessibility of chiropractic care affects spending on medical spine care among Medicare beneficiaries. STUDY DESIGN: Retrospective cohort study that used beneficiary relocation as a quasi-experiment. METHODS: We used a combination of national data on provider location and Medicare claims to perform a quasi-experimental study to examine the effect of chiropractic care accessibility on healthcare spending. We identified 84,679 older adults enrolled in Medicare with a spine condition who relocated once between 2010 and 2014. For each year, we measured accessibility using the variable-distance enhanced 2-step floating catchment area method. Using data for the years before and after relocation, we estimated the effect of moving to an area of lower or higher chiropractic accessibility on spine-related spending adjusted for access to medical physicians. RESULTS: There are approximately 45,000 active chiropractors in the United States, and local accessibility varies considerably. A negative dose-response relationship was observed for spine-related spending on medical evaluation and management as well as diagnostic imaging and testing (mean differences, $20 and $40, respectively, among those exposed to increasingly higher chiropractic accessibility; P <.05 for both). Associations with other types of spine-related spending were not significant. CONCLUSIONS: Among older adults, access to chiropractic care may reduce medical spending on services for spine conditions.

Health insurance design and conservative therapy for low back pain.

OBJECTIVES: To determine the association of health insurance benefit design features with choice of early conservative therapy for patients with new-onset low back pain (LBP). STUDY DESIGN: Observational study of 117,448 commercially insured adults 18 years or older presenting with an outpatient diagnosis of new-onset LBP between 2008 and 2013 as recorded in the OptumLabs Data Warehouse. METHODS: We identified patients who chose a primary care physician (PCP), physical therapist, or chiropractor as their entry-point provider. The main analyses were logistic regression models that estimated the likelihood of choosing a physical therapist versus a PCP and choosing a chiropractor versus a PCP. Key independent variables were health plan type, co-payment, deductible, and participation in a health reimbursement account (HRA) or health savings account (HSA). Models controlled for patient demographic and clinical characteristics. RESULTS: Selection of entry-point provider was moderately responsive to the incentives that patients faced. Those covered under plan types with greater restrictions on provider choice were less likely to choose conservative therapy compared with those covered under the least restrictive plan type. Results also indicated a general pattern of higher likelihood of treatment with physical therapy at lower levels of patient cost sharing. We did not observe consistent associations between participation in HRAs or HSAs and choice of conservative therapy. CONCLUSIONS: Modification of health insurance benefit designs offers an opportunity for creating greater value in treatment of new-onset LBP by encouraging patients to choose noninvasive conservative management that will result in long-term economic and social benefits.

Patterns and Perceived Benefits of Utilizing Seven Major Complementary Health Approaches in U.S. Older Adults.

Objectives: To examine patterns and perceived benefits of seven major complementary health approaches (CHA) among older adults in the United States. Methods: Data from the 2012 National Health Interview Survey (NHIS), which represents non-institutionalized adults aged 65 or older (n = 7,116 unweighted), were used. We elicited seven most common CHA used in older adults, which are acupuncture, herbal therapies, chiropractic, massage, meditation, Tai Chi, and yoga. Survey participants were asked to self-report perceived benefits (eg, maintaining health and stress reduction) in their CHA used. We estimated prevalence and perceived benefits of CHA use. We also investigated socio-demographic and clinical factors associated with the use of any of these seven CHA. Results: Overall, 29.2% of older adults used any of seven CHA in the past year. Most commonly used CHA included herbal therapies (18.1%), chiropractic (8.4%), and massage (5.7%). More than 60% of older CHA users reported that CHA were important for maintaining health and well-being. Other perceived benefits included improving overall health and feeling better (52.3%), giving a better sense of control over health (27.4%), and making it easier to cope with health problems (24.7%). Older adults with higher education and income levels, ≥2 chronic conditions, and functional limitations had greater odds of using CHA (p < .01, respectively). Conclusion: A substantial number of older CHA users reported CHA-related benefits. CHA may play a crucial role in improving health status among older adults. At the population level, further research on the effects of CHA use on bio-psycho-social outcomes is needed to promote healthy aging in older adults.

Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids.

OBJECTIVE: Pain relief resulting from services delivered by doctors of chiropractic may allow patients to use lower or less frequent doses of opioids, leading to reduced risk of adverse effects. The objective of this investigation was to evaluate the association between utilization of chiropractic services and the use of prescription opioid medications. DESIGN: The authors used a retrospective cohort design to analyze health insurance claims data. SETTING: The data source was the all payer claims database administered by the State of New Hampshire. The authors chose New Hampshire because health claims data were readily available for research, and in 2015, New Hampshire had the second-highest age-adjusted rate of drug overdose deaths in the United States. SUBJECTS: The study population comprised New Hampshire residents aged 18-99 years, enrolled in a health plan, and with at least two clinical office visits within 90 days for a primary diagnosis of low-back pain. The authors excluded subjects with a diagnosis of cancer. OUTCOME MEASURES: The authors measured likelihood of opioid prescription fill among recipients of services delivered by doctors of chiropractic compared with nonrecipients. They also compared the cohorts with regard to rates of prescription fills for opioids and associated charges. RESULTS: The adjusted likelihood of filling a prescription for an opioid analgesic was 55% lower among recipients compared with nonrecipients (odds ratio 0.45; 95% confidence interval 0.40-0.47; p < 0.0001). Average charges per person for opioid prescriptions were also significantly lower among recipients. CONCLUSIONS: Among New Hampshire adults with office visits for noncancer low-back pain, the likelihood of filling a prescription for an opioid analgesic was significantly lower for recipients of services delivered by doctors of chiropractic compared with nonrecipients. The underlying cause of this correlation remains unknown, indicating the need for further investigation.

Utilization of Chiropractic Care in US Children and Adolescents: A Cross-Sectional Study of the 2012 National Health Interview Survey.

OBJECTIVE: The purpose of this study was to describe the prevalence of chiropractic utilization and examine sociodemographic characteristics associated with utilization in a representative sample of US children and adolescents aged 4 to 17 years. METHODS: Data are from 9734 respondents to the 2012 National Health Interview Survey. Age, sex, race/ethnicity, geography, family income, parental educational attainment, and other health care providers served as exposure variables. Chiropractic utilization in the past 12 months (yes/no) was the targeted outcome. Weighted crude and adjusted logistic regression models, controlling for relevant covariates, were performed. RESULTS: The 12-month prevalence of chiropractic utilization in US children was 3.0% (95% confidence interval: 2.6%-3.6%). The adjusted odds (95% confidence interval) of chiropractic utilization were higher among 11- to 17-year-olds (2.02 [1.41-2.90]) (vs 4- to10-year-olds), Midwest residents (2.45 [1.36-4.44]) (vs Northeast), families with incomes ≥$100000 (3.25 [1.87-5.66]) (vs <$35000), and those that visited other Complementary and Integrative Health (also known as Complementary and Alternative Medicine) practitioners (11.26 [7.19-17.64]). Blacks and Asians had lower adjusted odds of chiropractic utilization compared with whites (0.17 [0.06-0.47] and 0.17 [0.07-0.43], respectively). Sex, parental education, and having an orthodox medical personal physician were not associated with utilization. CONCLUSION: Although overall prevalence was low, sociodemographic characteristics of child and adolescent users of chiropractic care were identified. Age, race/ethnicity, region of residence, family income, and utilization of other Complementary and Integrative Health services were associated with chiropractic utilization, after adjusting for sociodemographic covariates.

A Survey of the Scope of Chiropractic Practice in South Africa: 2015.

OBJECTIVES: The purpose of this study was to identify characteristics specific to the chiropractic profession in South Africa and compare them with those of other countries where similar surveys have been conducted. METHODS: This survey utilized a structured questionnaire designed to reflect chiropractic practice in South Africa. The questionnaire was made available online for completion by 714 chiropractic practitioners who were registered with the Allied Health Professions Council of South Africa in 2015. Participation was both voluntary and anonymous. RESULTS: The response rate was 32%; of the respondents, 56% were males and 44% were females. The majority of the respondents had a master's degree in chiropractic. Most participants worked between 31 and 40 hours and saw fewer than 50 patients per week, typically allocating 31 to 45 minutes for initial consultations and 16 to 30 minutes for follow-up visits. Participants saw more female patients than male patients, and most patients were between the ages of 31 and 50 years. Patients typically presented to chiropractors during the acute phase, the primary complaint was low back and pelvic pain/injury without leg pain, and overuse/repetitive stress was reported as being the common etiology. Chiropractors have developed interprofessional referral relationships with general practitioners and massage therapists. CONCLUSIONS: Compared with similar survey analyses from Switzerland, the United Kingdom, and the United States, our findings showed overlap, but some characteristics were unique to the chiropractic profession in South Africa.

Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina. METHODS: Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns. RESULTS: The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care. CONCLUSIONS: Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care.

Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by provider patterns of care for the treatment of neck pain in North Carolina. METHODS: This was an analysis of neck-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees (NCSHP) from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the NCSHP using ICD-9 diagnostic codes for uncomplicated neck pain (UNP) and complicated neck pain (CNP). RESULTS: Care patterns with single-provider types and no referrals incurred the least average charges for both UNP and CNP. When care did not include referral providers or services, for either UNP or CNP, MD care with PT was generally less expensive than MD care with DC care. However, when care involved referral providers or services, MD and PT care was on average more expensive than MD and DC care for either UNP or CNP. Risk-adjusted charges for patients in the middle quintile of risk (available 2006-2009) were lower for chiropractic patients with or without medical care or referral care to other providers. CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for UNP or CNP compared to MD care with or without PT care, when care included referral providers or services. This finding was reversed when care did not include referral providers or services. Risk-adjusted charges for UNP and CNP patients were lower for DC care patterns.

Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by patterns of care for the treatment of low back pain in North Carolina. METHODS: This was an analysis of low-back-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, 9th Revision diagnostic codes for uncomplicated low back pain (ULBP) and complicated low back pain (CLBP). RESULTS: Care patterns with single-provider types and no referrals incurred the least charges on average for both ULBP and CLBP. When care did not include referral providers or services, for ULBP, MD and DC care was on average $465 less than MD and PT care. For CLBP, MD and DC care averaged $965 more than MD and PT care. However, when care involved referral providers or services, MD and DC care was on average $1600 less when compared to MD and PT care for ULBP and $1885 less for CLBP. Risk-adjusted charges (available 2006-2009) for patients in the middle quintile of risk were significantly less for DC care patterns. CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for ULBP than MD care with or without PT care. This finding was reversed for CLBP. Adjusted charges for both ULBP and CLBP patients were significantly lower for DC patients.

Cross-Sectional Analysis of Per Capita Supply of Doctors of Chiropractic and Opioid Use in Younger Medicare Beneficiaries.

OBJECTIVE: The purpose of this study was to determine whether the per-capita supply of doctors of chiropractic (DCs) or Medicare spending on chiropractic care was associated with opioid use among younger, disabled Medicare beneficiaries. METHODS: Using 2011 data, at the hospital referral region level, we correlated the per-capita supply of DCs and spending on chiropractic manipulative therapy (CMT) with several measures of per-capita opioid use by younger, disabled Medicare beneficiaries. RESULTS: Per-capita supply of DCs and spending on CMT were strongly inversely correlated with the percentage of younger Medicare beneficiaries who had at least 1, as well as with 6 or more, opioid prescription fills. Neither measure was correlated with mean daily morphine equivalents per opioid user or per chronic opioid user. CONCLUSIONS: A higher per-capita supply of DCs and Medicare spending on CMT were inversely associated with younger, disabled Medicare beneficiaries obtaining an opioid prescription. However, neither measure was associated with opioid dosage among patients who obtained opioid prescriptions.

Insurance Coverage for Complementary Health Approaches Among Adult Users: United States, 2002 and 2012.

KEY FINDINGS: Data from the 2002 and 2012 National Health Interview Surveys. Between 2002 and 2012, the use of acupuncture, chiropractic, and massage therapy increased among adults who did not have health insurance coverage for these complementary health approaches. No change in use was observed among those who had coverage for these approaches. While 60% of adults who saw a practitioner for chiropractic had at least some health insurance coverage for this approach, far fewer adults seeing a practitioner for acupuncture (25%) or massage therapy (15%) had coverage for these approaches. Adults who saw practitioners for acupuncture and chiropractic-and had health insurance coverage for these approaches-were more likely to have partial than complete coverage.

Racial Disparities in Use of Chiropractic Services by Medicare Beneficiaries Aged 65 to 99 in Los Angeles County, California.

Racial and ethnic disparities in utilization of chiropractic services have been described at the state level, but little is known about such local disparities. We analyzed Medicare data for the year 2008 to evaluate by ZIP code for utilization of chiropractic services among older adults in Los Angeles County, California. We evaluated for availability and use of chiropractic services by racial/ethnic category, quantified geographic variations by coefficient of variation, and mapped utilization by selected racial/ethnic categories. Among 7502 beneficiaries who used chiropractic services, 72% were white, 12% Asian, 1% black, 1% Hispanic, and 14% other/unknown. Variation in the number of beneficiaries per ZIP code who used chiropractic services was highest among Hispanics, blacks, and Asians. We found evidence of racial disparities in use of chiropractic services at the local level in Los Angeles County. Older blacks and Hispanics in Los Angeles County may be underserved with regard to chiropractic care.

Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs.

RATIONALE, AIMS AND OBJECTIVE: Low back pain (LBP) care can involve many providers. The provider chosen for entry into care may predict future health care utilization and costs. The objective of this study was to explore associations between entry settings and future LBP-related utilization and costs. METHODS: A retrospective review of claims data identified new entries into health care for LBP. We examined the year after entry to identify utilization outcomes (imaging, surgeon or emergency visits, injections, surgery) and total LBP-related costs. Multivariate models with inverse probability weighting on propensity scores were used to evaluate relationships between utilization and cost outcomes with entry setting. RESULTS: 747 patients were identified (mean age = 38.2 (± 10.7) years, 61.2% female). Entry setting was primary care (n = 409, 54.8%), chiropractic (n = 207, 27.7%), physiatry (n = 83, 11.1%) and physical therapy (n = 48, 6.4%). Relative to primary care, entry in physiatry increased risk for radiographs (OR = 3.46, P = 0.001), advanced imaging (OR = 3.38, P < 0.001), injections (OR = 4.91, P < 0.001), surgery (OR = 4.76, P = 0.012) and LBP-related costs (standardized Β = 0.67, P < 0.001). Entry in chiropractic was associated with decreased risk for advanced imaging (OR = 0.21, P = 0.001) or a surgeon visit (OR = 0.13, P = 0.005) and increased episode of care duration (standardized Β = 0.51, P < 0.001). Entry in physical therapy decreased risk of radiographs (OR = 0.39, P = 0.017) and no patient entering in physical therapy had surgery. CONCLUSIONS: Entry setting for LBP was associated with future health care utilization and costs. Consideration of where patients chose to enter care may be a strategy to improve outcomes and reduce costs.

Public Perceptions of Doctors of Chiropractic: Results of a National Survey and Examination of Variation According to Respondents' Likelihood to Use Chiropractic, Experience With Chiropractic, and Chiropractic Supply in Local Health Care Markets.

OBJECTIVES: The purpose of this study was to determine whether general perceptions of doctors of chiropractic (DCs) varied according to likeliness to use chiropractic care, whether particular demographic characteristics were associated with chiropractic care use, and whether perception of DCs varied according to the per-capita supply of DCs in local health care markets. METHODS: We performed a secondary analysis of results from a 26-item nationally representative survey of 5422 members of The Gallup Panel that was conducted in the spring of 2015 (response rate, 29%) that sought to elicit the perceptions and use of DCs by US adults. We compared survey responses across: (1) respondents who had different likelihoods to use DCs for treatment of neck or back pain and (2) respondents who had different experiences using DCs. We linked respondents' zip codes to hospital referral regions for which we had the per-capita supply of DCs. Using the χ(2) test, we examined relationships between likeliness to use a DC, experience using a DC, respondent demographic variables, perceptions of DCs, and the per-capita supply of DCs in the local health care market. RESULTS: Most (61.4%) respondents believed that chiropractic care was effective at treating neck and back pain, 52.6% thought DCs were trustworthy, and 24.2% thought chiropractic care was dangerous; however, as respondents' likelihood to use a DC increased, perceptions of effectiveness and trustworthiness increased, and perceptions of danger decreased. Of all 5422 survey respondents, 744 or 13.7% indicated that they had seen a DC within the last 12 months. As one moved from distant to more recent experience using a DC, respondents were more likely to be female, married, white, and employed; those who had a distant history of using a DC were older and more likely to be retired than the other groups. A higher per-capita supply of DCs was associated with higher utilization rates and showed a more favorable regard for DCs. CONCLUSIONS: US adults often use chiropractic care, generally regard DCs favorably, and largely perceive that chiropractic care is safe. Where there is a higher per-capita supply of DCs in the local health care market, utilization and positive perceptions of chiropractic are higher.

Acupuncture and chiropractic care: utilization and electronic medical record capture.

OBJECTIVES: To describe acupuncture and chiropractic use among patients with chronic musculoskeletal pain (CMP) at a health maintenance organization, and explore issues of benefit design and electronic medical record (EMR) capture. STUDY DESIGN: Cross-sectional survey. METHODS: Kaiser Permanente members meeting EMR diagnostic criteria for CMP were invited to participate. The survey included questions about self-identified presence of CMP, use of acupuncture and chiropractic care, use of ancillary self-care modalities, and communication with conventional medicine practitioners. Analysis of survey data was supplemented with a retrospective review of EMR utilization data. RESULTS: Of 6068 survey respondents, 32% reported acupuncture use, 47% reported chiropractic use, 21% used both, and 42% used neither. For 25% of patients using acupuncture and 43% of those using chiropractic care, utilization was undetected by the EMR. Thirty-five percent of acupuncture users and 42% of chiropractic users did not discuss this care with their health maintenance organization (HMO) clinicians. Among chiropractic users, those accessing care out of plan were older (P < .01), were more likely to use long-term opioids (P = .03), and had more pain diagnoses (P = .01) than those accessing care via clinician referral or self-referral. For acupuncture, those using the clinician referral mechanism exhibited these same characteristics. CONCLUSIONS: A majority of participants had used acupuncture, chiropractic care, or both. While benefit structure may materially influence utilization patterns, many patients with CMP use acupuncture and chiropractic care without regard to their insurance coverage. A substantial percentage of acupuncture and chiropractic use thus occurs beyond detection of EMR systems, and many patients do not report such care to their HMO clinicians.

Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain.

BACKGROUND: Whether availability of chiropractic care affects use of primary care physician (PCP) services is unknown. METHODS: We performed a cross-sectional study of 17.7 million older adults who were enrolled in Medicare from 2010 to 2011. We examined the relationship between regional supply of chiropractic care and PCP services using Spearman correlation. Generalized linear models were used to examine the association between regional supply of chiropractic care and number of annual visits to PCPs for back and/or neck pain. RESULTS: We found a positive association between regional supply of chiropractic care and PCP services (rs = 0.52; P <.001). An inverse association between supply of chiropractic care and the number of annual visits to PCPs for back and/or neck pain was apparent. The number of PCP visits for back and/or neck pain was 8% lower (rate ratio, 0.92; 95% confidence interval, 0.91-0.92) in the quintile with the highest supply of chiropractic care compared to the lowest quintile. We estimate chiropractic care is associated with a reduction of 0.37 million visits to PCPs nationally, at a cost of $83.5 million. CONCLUSIONS: Greater availability of chiropractic care in some areas may be offsetting PCP services for back and/or neck pain among older adults.

Chiropractic use in the Medicare population: prevalence, patterns, and associations with 1-year changes in health and satisfaction with care.

OBJECTIVE: The purpose of this study was to examine how chiropractic care compares to medical treatments on 1-year changes in self-reported function, health, and satisfaction with care measures in a representative sample of Medicare beneficiaries. METHODS: Logistic regression using generalized estimating equations is used to model the effect of chiropractic relative to medical care on decline in 5 functional measures and 2 measures of self-rated health among 12170 person-year observations. The same method is used to estimate the comparative effect of chiropractic on 6 satisfaction with care measures. Two analytic approaches are used, the first assuming no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models. RESULTS: The unadjusted models show that chiropractic is significantly protective against 1-year decline in activities of daily living, lifting, stooping, walking, self-rated health, and worsening health after 1 year. Persons using chiropractic are more satisfied with their follow-up care and with the information provided to them. In addition to the protective effects of chiropractic in the unadjusted model, the propensity score results indicate a significant protective effect of chiropractic against decline in reaching. CONCLUSION: This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

Chiropractic use and changes in health among older medicare beneficiaries: a comparative effectiveness observational study.

OBJECTIVE: The purpose of this study was to investigate the effect of chiropractic on 5 outcomes among Medicare beneficiaries: increased difficulties performing activities of daily living (ADLs), instrumental ADLs (IADLs), and lower body functions, as well as lower self-rated health and increased depressive symptoms. METHODS: Among all beneficiaries, we estimated the effect of chiropractic use on changes in health outcomes among those who used chiropractic compared with those who did not, and among beneficiaries with back conditions, we estimated the effect of chiropractic use relative to medical care, both during a 2- to 15-year period. Two analytic approaches were used--one assumed no selection bias, whereas the other adjusted for potential selection bias using propensity score methods. RESULTS: Among all beneficiaries, propensity score analyses indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, and depressive symptoms, although there were increased risks associated with chiropractic for declines in lower body function and self-rated health. Propensity score analyses among beneficiaries with back conditions indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, lower body function, and depressive symptoms, although there was an increased risk associated with chiropractic use for declines in self-rated health. CONCLUSION: The evidence in this study suggests that chiropractic treatment has comparable effects on functional outcomes when compared with medical treatment for all Medicare beneficiaries, but increased risk for declines in self-rated health among beneficiaries with back conditions.

Medicare's demonstration of expanded coverage for chiropractic services: limitations of the demonstration and an alternative direct cost estimate.

OBJECTIVE: The purposes of this study were to examine the direct costs associated with Medicare's 2005-2007 "Demonstration of Expanded Coverage of Chiropractic Services" (Demonstration) and their drivers, to explore practice pattern variation during the Demonstration, and to describe scenarios of cost implications had provider behavior and benefit coverage been different. METHODS: Using Medicare Part B data from April 1, 2005, and March 31, 2007, and 2004 Rural Urban Continuum Codes, we conducted a retrospective analysis of traditionally reimbursed and expanded chiropractic services provided to patients aged 65 to 99 years who had a neuromusculoskeletal condition. We compared chiropractic care costs, supply, and utilization patterns for the 2-year periods before, during, and after the Demonstration for 5 Chicago area counties that participated in the Demonstration to those for 6 other county aggregations-urban or rural counties that participated in the Demonstration; were designated comparison counties during the Demonstration; or were neither participating nor comparison counties during the Demonstration. RESULTS: When compared with other groups, doctors of chiropractic in 1 region (Chicago area counties) billed more aggressively for expanded services and were reimbursed significantly more for traditionally reimbursed chiropractic services provided before, during, and after the Demonstration. Costs would have been substantially lower had doctors of chiropractic in this 1 region had responded similarly to those in other demonstration counties. CONCLUSION: We found widespread geographic variation in practice behavior and patterns. Our findings suggest that Medicare might reduce the risk of accelerated costs associated with the introduction of a new benefit by applying appropriate limits to the frequency of use and overall costs of those benefits, particularly in highly competitive markets.